Docs generally following cancer patient guidelines

NEW YORK (Reuters Health) - Most older cancer patients are getting treatment that is in line with current expert guidelines, suggests a new study that looked at variations in surgical care for several cancers.

However, doctors didn't follow guidelines as closely for certain procedures -- especially when evidence for the "correct" treatment decision wasn't as convincing, according to the report published in Archives of Surgery.

The researchers, led by Dr. Caprice Greenberg of Brigham and Women's Hospital in Boston, compared the cancer care given to people on Medicare with treatment guidelines from the National Institutes of Health and cancer organizations.

"When there's really good evidence (for a specific treatment) it looks like people are pretty consistently getting that kind of care," Greenberg told Reuters Health.

But "if guidelines are based on consensus of what people think might be the right thing to do, guidelines aren't consistently followed," she added.

Greenberg said that finding points to a need for more studies to evaluate treatments for different cancers, in order to give doctors confidence in surgery guidelines.

For their report, Greenberg and her colleagues analyzed records from a database of people on Medicare -- all aged 65 and up -- with a new diagnosis of one of five types of cancer. The final pool included more than 100,000 people who had surgery for breast, colon, gastric, rectal or thyroid cancer between 2000 and 2005.

Guidelines for those diseases outline which patients, based on their cancer type and stage, should be referred for chemotherapy or radiation. For some cancers, the recommendations specify what type of surgery needs to be done for doctors to make an informed decision about further treatment.

Greenberg found that hospitals treated more than 90 percent of patients with breast, colon, and rectal cancer according to guidelines -- performing chemotherapy or radiation or referring them to another doctor for that purpose.

Hospitals were best about following guidelines for breast cancer surgery --possibly, the authors note, because those guidelines have been around for a long time, and there's lots of evidence backing them up.

Less than half of hospitals, however, followed guidelines related to surgery to remove groups of immune cell repositories called lymph nodes in patients with colon or gastric cancer. Removing more nodes can help doctors figure out if a cancer has started to spread and needs more intense treatment than one in its earlier stages. The guidelines call for a minimum number of nodes to be taken out and examined in each case.

But there's less evidence telling doctors exactly how to treat those patients, the researchers noted.

"Everyone knows that getting more lymph nodes is generally a good thing, but we don't necessarily know how many is a right number, or is that true for everybody," Greenberg said.

Chang, who studies colorectal cancer at MD Anderson Cancer Center in Houston and was not involved in the new research, said it was noteworthy that so few patients had enough nodes removed -- 12, for colon cancer -- to meet the guidelines in this study. He said that may be in part because the surgery isn't a yes or no call, like the decision to refer a breast cancer patient for chemotherapy.

But Chang also added that in the years since this data was collected, studies have shown that doctors are getting better at following colon cancer guidelines.

Still, when it comes to cancer surgery, Greenberg said, "we don't yet know for sure what the right thing is to do in all cases." She said more data is needed to make that clearer.

Previous studies have suggested that doctors may give some people with cancer or other diseases tests and treatments beyond what guidelines suggest. One found, for example, that too many patients with low-risk thyroid cancer are treated with radioactive iodine -- only recommended for higher-risk tumors, in part because it may carry a risk of secondary cancer (see Reuters Health story of April 15, 2011.)

"We do need to improve the quality of evidence," Chang told Reuters Health. "I think the question becomes how much more evidence is necessary" for doctors to be confident about following guidelines. "That's always the challenge."

"The most important thing I think is to talk to your physicians about why they're recommending the treatment they're recommending," Greenberg concluded, "and to make the decision together."